The Peter Attia Drive - #113： Normative errors—a conversation with my daughter about current events

00:00:00.000 Hey folks, welcome to a special episode that deals with kind of the aftermath and some of

00:00:04.260 the questions that are surrounding us in the wake of the brutal death of George Floyd.

00:00:09.320 A lot of people have been speaking about this in their own way, choosing to post various

00:00:13.060 things on social media.

00:00:14.140 I've never really thought I had much to offer with respect to doing stuff like that.

00:00:19.040 For me, it's been a very difficult couple of days kind of just thinking about this stuff

00:00:22.200 and not really knowing how to explain it to my daughter who has been asking a lot of questions

00:00:28.940 about it. And I kind of wrestled with this idea of doing a podcast or not. And in the end,

00:00:33.540 I sort of decided this evening after dinner that, you know, I was going to do this. So

00:00:36.940 Olivia and I sat down for maybe 20 minutes or something to talk about stuff that we have been

00:00:41.580 talking about all week. And I really wanted to talk more in terms of something that I had some

00:00:48.720 knowledge of. I don't consider myself an expert in law enforcement, racism, the history of police

00:00:54.340 brutality, all of the things that, you know, might factor into this. But there is one area

00:00:59.000 that I do think I have some knowledge in that I can speak to. And it has to do with the training of

00:01:04.300 physicians. And there's something I've thought a lot about. So I approach this conversation with

00:01:09.980 Olivia as I often approach conversations with her, which is sort of touching on a framework

00:01:14.200 and an understanding. Then maybe that's broader than this problem. As with all podcasts,

00:01:19.340 of course, I can't address all things. And that's more true in this podcast than

00:01:22.900 probably any podcast I'll ever produce. But I do talk about one very particular way that I

00:01:29.240 think about what's going on and perhaps more importantly, how we can start to get a handle

00:01:34.160 on it. This podcast might not be for you. If it doesn't resonate with you, I apologize. But

00:01:38.520 I think that for some folks, especially folks with kids who are struggling to kind of explain to them

00:01:43.480 what's going on, perhaps you'll find this helpful.

00:01:50.100 Hi, Olivia. Thanks for sitting down to talk for a few minutes tonight.

00:01:52.900 Yeah. So there's been a lot going on for the last few days. And I know you're in the middle of

00:01:57.860 finals. And I know that if that weren't enough, you've got a quarantine going on that you're

00:02:02.680 probably kind of at your wits end with. But tell me a little bit about how you feel about the last

00:02:07.760 few days and how you've heard about it and what you and your friends are talking about.

00:02:12.660 At first, I was seeing it on everyone's Instagram, justice for George. And I was confused. I was like,

00:02:17.700 what is that? And then I started looking it up and I was like, whoa, this just happened.

00:02:22.660 And then I started reading articles about it to see what happened. And this is the first time that

00:02:28.680 I've actually heard about something like this that's happened recently. Because the only ever times I've

00:02:34.320 heard about it is when I was younger and I don't remember it. But everyone that I text is sending like

00:02:40.600 Black Lives Matter and they're all doing different color fists. And I think that's great that they're 1.00

00:02:45.240 noticing what's happening. And I just don't understand how this could happen. Because like,

00:02:50.400 would people judge you about the color of your eyes? Like, what's the difference with skin color?

00:02:54.440 I mean, it's a very complicated question, Olivia. And it goes back hundreds of years. And you know how

00:03:00.400 the other day we were talking about all the different things in school that I'm really looking

00:03:04.460 forward to you learning in greater detail? Well, one of those things is history. And I don't think

00:03:11.120 you've yet really fully understood the history of how Black people came to this country and what terms

00:03:19.460 that was under and what conditions of racism produced it and allowed it to continue for literally

00:03:28.900 hundreds of years. And I hope that when you get to studying history, you will understand that it's not

00:03:36.300 just about taking tests and passing tests and getting answers or writing essays, but it's about

00:03:40.700 really understanding the systemic nature of racism. I want to tell you an interesting story that I've

00:03:47.200 never told you before. I don't think I've ever told mom this story either. So I kind of have slightly

00:03:52.240 different skin color, right? Like if you look at me, you know, I'm not perfectly white. I'm not black.

00:03:57.220 I mean, I kind of look like I look like I'm something, right? You also have slightly darker skin

00:04:03.080 as a result of that. So when I was in college, which was in an area that was pretty much exclusively

00:04:10.440 white people. One day I was, it was 1995. I remember this very well. I was riding my bike

00:04:17.520 to the gym. I used to go to this gym a couple of miles from my house and I'm riding my bike

00:04:22.140 and you're supposed to ride your bike on the right side of the road. But like, I don't know,

00:04:27.660 I forget. I think there was like a lot of water and snow in the ground. So I rode up on the sidewalk

00:04:31.980 and a police officer pulled his car right in front of me and yanked me off my bike and threw 0.68

00:04:40.460 me onto the grass right in front of where I went to the gym. This all took place right in front of

00:04:46.680 the gym that I went to. And I basically stood up and said, what the F man? And he said, were you in

00:04:54.360 such and such a place at such and such a time? And I'm like, what are you talking about? He goes,

00:04:58.480 you can't ride your bike here. And I was like, totally confused by what was going on. He kept

00:05:02.620 going back and forth between, I'm not allowed to ride my bike on the sidewalk. And then sort of

00:05:06.760 making these accusations. And he said, an older woman was mugged near here like yesterday or something

00:05:14.960 like that. And it was really clear at that point, what he was basically saying, which was you did this

00:05:20.860 and I can't prove it, but that's my suspicion. I don't like the way you look. And the fact that

00:05:27.240 you're riding your bike on a sidewalk where you shouldn't be riding it is my chance to make that

00:05:32.880 case. Eventually a whole bunch of people came out from the gym, apparently including somebody who was

00:05:39.480 kind of related to him. It was a small town that I went to college in and he basically let me walk

00:05:45.240 away. And I was pretty shaken up about that. That was super upsetting to me. And of course, to put

00:05:52.040 that in the perspective of what we're talking about today, that's like one, one millionth of the type

00:05:57.760 of racial profiling and racial discrimination that is experienced by black people in the United States

00:06:04.100 and elsewhere, but certainly in the United States on a daily basis. Something that, I mean, you just

00:06:09.780 won't understand and nor will I. Why do you think he did that? I think it's a combination of factors

00:06:14.840 in my example. I think certainly racism played a role. I don't believe that he would have done

00:06:20.740 that to anybody else necessarily. But I also think in that case, there was some indication that he

00:06:26.920 legitimately felt like, hey, this is a guy, there's a kid who's riding on the wrong side of the road or

00:06:32.660 up on the sidewalk and he shouldn't be. And oh, by the way, I have a reason of suspicion that there's

00:06:37.280 some bad apple somewhere out here and this is what I'm going to do. And it's hard to imagine

00:06:44.560 that times a thousand. And that's what's going on in the case of someone like George Floyd or

00:06:52.860 any one of the other people whose names we don't know. Remember, the reason we know about this,

00:06:57.880 Olivia, is it's caught on video. Yeah. There can be so many other people just like this that we

00:07:02.540 don't know about. Well, that's exactly right. And you have to think about, imagine an era when you

00:07:06.520 didn't have cell phones that we could capture anything and everything by video. How many times do

00:07:10.820 you think this has already happened? Probably more than we can count. Yeah. You would need

00:07:15.220 scientific notation to count the number of times this has happened. So when I was reading the article

00:07:21.580 where I started to learn about this, I saw, so when George Floyd was in the deli and he gave a check

00:07:29.820 that people thought was fake, I saw a comment in the article that said, one time I went to Home Depot

00:07:36.520 and I used a fake $20 bill and they knew it was fake and they gave it back to me and let me just

00:07:41.540 walk out because I was white. Yeah. There's absolutely no question that a white person and

00:07:47.040 a black person has a completely different interaction with, frankly, law enforcement,

00:07:53.040 the criminal justice system, all of these things. I'm glad to see how much this is upsetting you.

00:07:58.780 It's good to see that this is upsetting to you. As much as I hate to see a kid upset,

00:08:03.500 it should upset you. It should upset you greatly. Well, why do you think that police officers do

00:08:08.640 this? I mean, the only difference is that some people have darker skin, some people have lighter

00:08:13.480 skin. Why, why does that make them more likely to get killed or hurt? I mean, it comes down to

00:08:19.400 racism. This is what we call systemic racism. And so the real question is, why is it tolerated

00:08:27.280 in the police force? Yeah. Shouldn't there be some sort of, I don't know how to put this,

00:08:33.200 but like a test to see if you're not racist before they let you on to be a police officer? Because it's

00:08:39.740 not fair that innocent people are getting killed because of this. Yeah. I mean, I've been thinking

00:08:43.760 about this a lot, Olivia. I've seen some people who are very thoughtful make comments like,

00:08:48.060 hey, look, there are very few protesters that are actually looting and there are very few police

00:08:53.720 officers that are going to do what this guy did. It's mostly good police officers and mostly good

00:08:59.300 protesters. And they, you know, we're focusing most of our attention on the worst of both groups.

00:09:04.740 There may be some truth to that, but a counter argument to that is, isn't law enforcement

00:09:10.760 a profession in which we can't tolerate any of this? Don't we need a zero tolerance policy for this?

00:09:17.020 Would you want to fly on airplanes? I think Chris Rock used this analogy. Would you want to fly on

00:09:23.280 airplanes where 99% of the pilots were good and 1% were horrible? No, you wouldn't because that 1%

00:09:30.260 could make a difference that they're horrible. Yeah. It's, it's totally unacceptable paradigm. So

00:09:35.880 I've been thinking about this a little bit and I, and I actually realized that I don't know what the

00:09:40.920 analogy is and I don't know if that, you know, airlines are the right analogy, but I think a good

00:09:45.220 analogy is actually doctors. Comparing doctors to police officers is better than trying to compare

00:09:50.240 police officers to pilots because, well, one, I think there are probably more interactions that

00:10:01.240 are interpersonal that are the ones that we're really talking about. You know, I think that's

00:10:05.140 probably the most different thing. And when you, when you talk about a pilot being ethical or not

00:10:09.820 ethical, moral or amoral, and of course, by the way, there are examples of pilots that have done very

00:10:15.220 bad things. There are pilots that have crashed airplanes deliberately, but the frequency of that

00:10:19.760 is so incredibly low. But in medicine, there really are some bad doctors out there. And I don't mean

00:10:25.340 bad doctors that aren't smart. I mean, doctors that do horrible things that abuse patients. There's a very

00:10:33.520 famous doctor. He was the doctor of the U S gymnastics team, and he abused many of the gymnasts. I mean,

00:10:40.840 these are despicable doctors. And so I wonder if that's a better analogy. And in medicine, 0.86

00:10:46.020 there are basically three types of mistakes you can make. And I think of this as a very important

00:10:50.500 way to think about how you train people. There are technical mistakes. There are judgment mistakes.

00:10:57.600 There are normative mistakes. Do any of those words mean anything to you? Normative mistakes that can

00:11:03.820 mean like mistakes that you don't mean to cause? No, actually that's not what normative is. So let me

00:11:09.080 explain what these are. So a technical mistake is like, if you think about surgery, which is the

00:11:14.360 easiest place to explain it, a technical error is you mean to do something, but you make a mistake.

00:11:20.240 You cut too much, you cut too little, you poke too much, you poke too little. The patient is hurt as a

00:11:25.620 result of a technical error that you make. I've made many technical errors in my residency when I was

00:11:32.480 training. You know, I, I remember once doing an operation on a patient and I cut the bile duct by

00:11:37.800 accident, you know, when I didn't mean to doing, doing an operation. Do we forgive people who make

00:11:43.400 those kinds of mistakes? Yeah. Cause it wasn't, they didn't want to do that. That's true. But

00:11:48.400 there's a bigger and a more important point there. We forgive them provided what they have to own the

00:11:54.960 mistake immediately. They can never try to cover it up. They can't deny it. They have to own up to

00:12:00.260 their mistake and not hide the fact that they made a mistake about that. That's right. The other

00:12:05.420 condition to that is you must learn from your mistakes and not make the same mistakes over and

00:12:10.960 over again. So if I cut the bile duct every single week, well, that would be a problem,

00:12:15.600 right? If I'm putting a central line in a patient, which is a special IV that goes into their neck

00:12:21.160 and I constantly poke their lung, which causes a huge catastrophe of problems.

00:12:27.240 And even if I admit to it every time, but never get better, that is a problem.

00:12:30.660 That's also not helpful. Even if you do admit it, that's still not going to make it.

00:12:34.480 Yeah. At some point you just have to decide you're, maybe you're not technically capable

00:12:37.480 of doing this job. So that's a technical error. Then there's an error of judgment.

00:12:42.940 Judgment errors are a little harder to understand, but it basically says, should I, or should I not

00:12:47.480 operate on this patient now? Should I, or should I not change this medication now? Should I, or should

00:12:53.640 I not admit this patient to the hospital now or send this patient home or call in another doctor to

00:12:58.380 help consult with this? Now, again, you can make lots of mistakes with respect to judgment. Are

00:13:04.340 they forgivable? They can be as long as you own up to what you did. And you don't repeat them. And you

00:13:10.180 don't repeat them. Okay. Now enter normative errors. Normative errors are the third class of error in

00:13:17.220 training physicians. These are errors of character. This is when you lie about something. Let me give you

00:13:27.060 examples that I witnessed firsthand. You go in to see a patient in the emergency room who comes in

00:13:33.280 with an infection and you give them an antibiotic. You don't ask them if they're allergic to the

00:13:39.040 antibiotic. They have an allergic reaction to the antibiotic. You go back and change the form where it

00:13:45.900 says, what was their allergy to the antibiotic? And you write in, oh, they had a penicillin allergy,

00:13:50.440 even though you didn't ask them. Seems like a little error, doesn't it?

00:13:53.860 No. Why? Why isn't that just a little error?

00:13:57.400 Because when you lie about something that you did like that, that just makes it worse.

00:14:02.160 Well, what if in that case, the patient was fine? You gave them penicillin. They had an allergy to

00:14:06.860 the penicillin. You gave them the appropriate Benadryl or epinephrine or whatever they needed

00:14:11.280 to not die from it. And they're totally fine. But you went back and you changed your form.

00:14:16.740 That's still not right.

00:14:18.220 Why is it not right?

00:14:19.680 Well, you have to live with the fact that you did that. And you could have hurt them if you didn't

00:14:23.300 know how to fix it.

00:14:24.120 That's true. And there's an even deeper issue, which is people who consistently make those kinds

00:14:30.300 of mistakes or frankly, make those kinds of mistakes at all, will go on to make bigger and

00:14:35.040 bigger and bigger.

00:14:35.660 They won't learn from it.

00:14:36.680 That's right. They make bigger and bigger versions of those mistakes. And so a good training system in

00:14:44.160 medicine is one that fosters and encourages open and honest discussion of technical errors

00:14:51.040 errors and judgment errors, but it immediately identifies normative errors and kicks those

00:14:57.420 people out of programs. And not just kicks those people out of programs, kicks those people out

00:15:02.200 of medicine. If a person commits a normative error and they are kicked out of one program only to be

00:15:08.740 picked up by another program, that hasn't really solved the problem.

00:15:11.880 They can just still make more mistakes like that.

00:15:13.780 That's right. They're still going to make their way into the field and the practice of medicine.

00:15:17.200 And so as I think about these awful things that have happened and I start to think about what can

00:15:23.300 I do about it? Well, the short answer is I have no clue. I know what to do in terms of voting and

00:15:28.620 I know what to do in terms of protesting and I know what to do with those things. But the thing that

00:15:32.680 I think a lot about is how do you change the training? How do you identify systemic racism in

00:15:39.420 training? And to me, it comes down to basically identifying traits that are prevalent in a way

00:15:47.200 that are going to be amplified this way later on. Does that make sense? In other words, we should be

00:15:51.980 treating racism as a normative error. And when it shows up in even the smallest ways, it has to be

00:15:59.260 tolerated zero. Just as we wouldn't tolerate a doctor who says, oh, uh, yeah, yeah, yeah. Um, I did ask

00:16:07.740 that patient if they had an allergy and they said nothing. I don't know what they're talking about.

00:16:10.880 I can't believe they had a penicillin allergy. You have to be very careful. And I know it sounds

00:16:14.420 like a silly example, but Olivia, I've seen lots of people make those normative errors where they lie

00:16:20.580 about things. They put their own interests ahead of a patient's interest. Another example, 0.52

00:16:26.340 I've seen doctors do it financially. For example, there are two drugs that you could give a patient

00:16:34.040 and the doctor has a financial interest to use one instead of the other. And they use the more

00:16:39.780 expensive one because they have a financial interest in that. Again, it's another example

00:16:44.880 of a normative error. So I don't know if I answered some of your questions because you've

00:16:51.760 been asking me so many great questions in the last couple of days, but I think that somewhere down

00:16:57.180 the line, people a lot smarter than me have to understand what the normative equivalent looks

00:17:04.400 like to the type of racism that can lead to a police officer putting his knee on the neck of a

00:17:12.160 black man for nearly nine minutes for no apparent reason. Cause that can't be hit the first time he has 1.00

00:17:20.980 acted in a racist way. That guy's been a racist for a long time. Why didn't we figure that out? 0.90

00:17:27.420 Yeah. What's the norm? That's, that's the guy who is so far down the road that he's cutting off

00:17:32.460 the patient's wrong leg out of sheer sloppiness. Then he should be more than just fired for doing

00:17:40.020 that. Cause if this is repetitive, that's not right. Yeah. And that's my point. It's not even right

00:17:45.340 to do it at one time, but multiple times. Well, my point is how do we know what, what was seen the

00:17:50.660 first time? I mean, at some point, I mean, not to get too far down this path, you have to have a

00:17:55.820 self policing system. And this is not true in most systems. And so I'm not, I'm not singling out

00:18:02.180 police officers here because I don't think doctors like to police other doctors any more than police

00:18:08.520 officers like to police other, you know, police themselves or teachers want to police teachers.

00:18:13.340 But remember, racism exists in a lot of professions. It exists in medicine. It exists in justice. It

00:18:21.740 exists in education. It exists everywhere. It certainly exists in the military. It's just the

00:18:27.620 stakes are so high in law enforcement that that's why we're seeing it the way we're seeing it here.

00:18:34.880 And I think the point I want to make tonight, as we sit here and try to make sense of this is

00:18:39.520 I hope that there's a way that we can take this idea of normative errors as a tool that we can use

00:18:48.380 to identify people who are making mistakes that are acceptable because they can be learned from and

00:18:53.860 improved upon versus unacceptable mistakes and quickly getting those people out of the system.

00:19:00.460 It's one thing to say we may never completely eradicate racism. It's quite another thing to say

00:19:05.520 we're going to tolerate racist police officers. You see the difference? The stakes are much higher.

00:19:11.020 The biggest question is what can we even do about this?

00:19:14.480 There is probably one of the best videos I've seen going around on this. I'm going to show it to

00:19:20.800 you later today. It's by this rapper and activist, Killer Mike. And he was at a press conference and he

00:19:27.980 gave a very eloquent, passionate speech about what exactly you can and can't do. And it was like, hey,

00:19:36.320 rioting, looting, that's not the thing to do. Yes, I know you're angry. Yes, you have every reason to be

00:19:42.560 upset, but that's not the productive thing to do. The productive thing to do is not just march and not

00:19:49.120 just send your fisted emoji to your friend. It's actually do something political. It's changed the

00:19:58.600 system, right? It's vote out the people who allow this type of racism to proliferate. That's one 0.99

00:20:06.040 example. I thought that was a very elegant example. Have you guys talked about this in school? Like

00:20:11.320 actually formally in any of your classes? For some reason, teachers don't talk about politics like this

00:20:17.480 in school, but I wish they did because I want to know more about it. That's so crazy to me.

00:20:22.440 Your teachers have not said anything about this? No. What do you guys think about that? As students,

00:20:28.580 do you talk about it amongst yourselves and say, why are they not saying anything? Yeah, all these group

00:20:33.620 chats in my grade are blowing up right now, but the teachers don't really do anything. Hmm. Well,

00:20:40.240 I don't know what to say about that, but I'm glad that you and I get to talk about it. Yeah.

00:20:43.280 Thank you. All right. Well, thanks for making time to sit down tonight. I know you got to get back to

00:20:49.120 studying. Bye. Thank you for listening to this week's episode of The Drive. This podcast is for

00:20:55.980 general informational purposes only and does not constitute the practice of medicine, nursing, or

00:21:00.720 other professional healthcare services, including the giving of medical advice. No doctor-patient

00:21:06.660 relationship is formed. The use of this information and the materials linked to this podcast

00:21:11.420 is at the user's own risk. The content on this podcast is not intended to be a substitute for

00:21:17.460 professional medical advice, diagnosis, or treatment. Users should not disregard or delay in

00:21:24.120 obtaining medical advice from any medical condition they have, and they should seek the assistance of

00:21:29.500 their healthcare professionals for any such conditions. Finally, I take conflicts of interest very

00:21:35.580 seriously for all of my disclosures and the companies I invest in or advise, please visit

00:21:41.180 peteratiamd.com forward slash about where I keep an up-to-date and active list of such companies.

00:22:05.580 Thank you.

00:22:15.180 You

The Peter Attia Drive - June 03, 2020

#113： Normative errors—a conversation with my daughter about current events

Episode Stats

Summary

Transcript